The Nurse Is Caring for a 79-Year-Old Male Who Has

The nurse is caring for a 79-year-old male who has a non-weight-bearing cast on the left lower extremity.The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance.Which response by the nurse is most likely to keep the patient from falling?

A) Apply a vest restraint and offer frequent toileting.
B) Plan fall prevention with patient, family, and healthcare provider.
C) Inform family that the patient needs physical restraints.
D) Document that the patient has a high potential for falling.